RCoA representation to the Comprehensive Spending Review 2020

Comprehensive Spending Review 2020 - Representation from the Royal College of Anaesthetists

This representation sets out what the RCoA believes is needed to put the anaesthetic workforce on a more sustainable footing to enable it to meet the increasing demands for hospital services and the additional pressures brought about by the COVID-19 pandemic. 

The vital role of anaesthesia in the NHS and during COVID-19

Anaesthesia is the single largest hospital specialty in the UK, and anaesthetists play a critical role in the care of two-thirds of all hospital patients. The specialty of anaesthesia has been at the heart of managing the sickest COVID-19 patients in high risk environments and is front and centre in the efforts to restore surgical services following the peak of the pandemic while still managing COVID patients[1]. Their unique skillset and training allow anaesthetists to be quickly cross-skilled and redeployed to support Intensive Care, making them an essential component of the NHS services and the ‘reserve’ workforce which will be needed to manage future COVID-19 surges and pandemics.

These pressures are compounded by an ageing population and increasing burden of complex multi-morbidities that are driving demand for healthcare services. There will be an additional 8.2 million people aged 65 and over in the UK by 2068[2]. At the same time, advances in medicine, including less invasive surgical techniques, have led to an increase in the number of older patients living longer with complex diseases and better tolerating the stresses of surgery. NHS Digital has calculated a 2.8% average annual growth over the last twenty years in Finished Consultant Episodes (continuous period of care under one hospital consultant)[3]. In addition, repeated annual winter pressures are putting unprecedented strain on the NHS and surgical services and will continue to do so for years to come.

Current workforce trends for the specialty of anaesthesia

Data collected through the latest RCoA Medical Workforce Census 2020[4] paints a worrying downward trend for the UK anaesthetic workforce:

  • The mean growth rate for consultant anaesthetists across the UK, 2007-2020 is now at 2.1% per year, less than the 2.3% growth rate per year, 2007-2015 noted in the last College census
  • More than 90% of anaesthetic departments in the UK have at least one unfilled consultant post
  • A comparison of previous censuses with the latest 2020 census shows that the funded workforce gap in consultant anaesthetists has been steadily increasing across the UK from 4.4% in 2015 to 8% in 2020, and that the aspirational gap (the number of anaesthetists required to deliver the service sustainably) is currently at 12%
  • There were 680 funded but unfilled consultant posts at the time of completing the latest census
  • The anaesthetic workforce is ageing. The number of consultants who now work beyond 60 and approaching retirement is up from 5% in 2015 to 7% in 2020.
  • Specialty and Associate Specialist (SAS) and Trust doctor numbers are unchanged compared to the 2015 Census, despite increased demand and their key role in delivery of anaesthetic services and, in many instances, supporting anaesthetic rota gaps

The growth rate of the consultant workforce and ability of anaesthetic departments to recruit anaesthetists to meet local demands are directly dependent and limited by the supply of new anaesthetists coming through specialist training. At the time of completing the census, there were approximately 4,000 training grade anaesthetists who should reach Certificate of Completion of Training (CCT) and be able to enter the GMC specialist register over the next 5 years. However, demand is growing at a faster pace leading to a predicted increasing workforce gap over the coming years. The effect of anaesthetists in training abandoning a career in anaesthesia must also be taken into consideration. An analysis by the RCoA Workforce Strategy Committee in 2014-2016 shows that the attrition rate for anaesthetist in training has been in the order of 25%[5].

Anaesthetic workforce requirements to meet demand

In 2015 the Centre for Workforce Intelligence (CfWI) reported an unmet need of 15% for anaesthetics and 25% for ICM. Modelling predicted that both specialties were likely to grow at 4.7% per year and without action demand would outstrip supply[6]. Our latest census reveals that the specialty has grown at a much slower rate than predicted by CfWI. Yet Health Education England has seen its budget fall from £5.3bn in 2013/14 to £4.2bn in 2019/20. This not only affects the number of training places available, but the quality of training and the level of support available for doctors in training.

Based on the workforce gaps identified by our latest census, we estimate that an additional 600 to 700 anaesthetists in training will be required over the next seven years (the length of the full anaesthetic training programme) to meet future demand. However, the ability of anaesthetic departments to accommodate an increased number of trainees needs to be also considered.

The RCoA recommends the adoption of a sustainable, long-term approach to the funding of medical training places in the UK, which takes into account long-term workforce planning requirements at system level, the ability of hospitals to accommodate trainees and the experience and quality of training for doctors. In the case of anaesthesia this would be achieved with an additional 50 core and specialist trainees per year over a period of 14 years. With the cost of anaesthetic training to HEE calculated at £245,283 per trainee over the seven year programme this would equate to a total investment of £24.5 million to train these 14 cohorts of an additional 50 trainees.  

A sustainable health and care workforce is necessary to deliver the NHS People Plan for 2020/21 and its aspirations for ‘finding new ways of working and delivering care, and responding to new challenges and opportunities’. Anaesthetists, alongside Anaesthesia Associates, will continue acting as the lynchpin of hospital services, facilitating multidisciplinary working and integrated care with community and primary care settings, managing the highest risk surgical and COVID-19 patients and developing solutions to deliver 21st century healthcare during the COVID-19 era and beyond.

Perioperative care

The remit of anaesthetists extends well beyond the operating theatre. Anaesthetists are increasingly responsible for managing the optimisation of surgical patients through perioperative care interventions by encouraging changes in lifestyle to improve outcomes and thus supporting prevention, population health and the NHS.  New, pioneering UK and international evidence[7] from the Centre for Perioperative Care that considered 27,000 studies, has proven that perioperative care pathways and their components can help to:

  • reduce the amount of time that people stay in hospital after surgery by an average of 1-2 days
  • reduce the use of intensive care units after surgery
  • reduce complication rates after surgery by 30-80%, meaning fewer resources are spent on this
  • reduce the cost of care or cost the same as conventional care

Perioperative care can be at the heart of the Secretary of State for Health and Social Care’s commitment to ‘build back better’. We are keen to work with the Treasury to fund rapid implementation of perioperative care pathways, and to improve funding of medical research to focus on other aspects of perioperative care where the evidence remains lacking or unclear.

Finally, the RCoA is a signatory of the Joint Statement to the Government on Public Health Reorganisation, which highlights the importance of funding, infrastructure and collaboration between health and social care settings for public health.[8] Anaesthetists, as perioperative physicians, play a critical role in promoting health improvement and reducing health inequalities for the millions of patients having surgery every year.

For more information please contact Elena Fabbrani, Policy and Patient Information Manager, efabbrani@rcoa.ac.uk.

About the Royal College of Anaesthetists

With a combined membership of 23,000 fellows and members, representing the three specialties of anaesthesia, intensive care and pain medicine, the Royal College of Anaesthetists (RCoA) is the third largest medical royal college by UK membership, and anaesthesia the single largest hospital specialty in the UK.

[1] RCoA. View from the frontline of Anaesthesia during COVID-19. Member surveys, April-July 2020.

[2] Office for National Statistics. Overview of the UK population: August 2019.   

[3] NHS Digital. Hospital Admitted Patient Care and Adult Critical Care Activity 2018-19. September 2019

[4] RCoA. Medical Workforce Census Report 2020 (due for publication November 2020 - data available on request)

[5] RCoA. Workforce Data Pack 2018. March 2018

[6] CfWI. In-depth review of the anaesthetics and intensive care medicine workforce. February 2015  

[7] RCoA. Impact of Perioperative Care on healthcare resource use – rapid research review. June 2020

[8] Smokefree Action Coalition. Joint Statement to the Government on Public Health Reorganisation. September 2020